Análisis Causa-Raíz Sobre Evento Adverso Producido en la Clínica Odontológica Docente Asistencial, Facultad de Odontología, Universidad de La Frontera, Chile

  1. Fernando Rivera-Mendoza 1
  2. Claudia Acevedo-Atala 1
  3. Bernardo Perea-Pérez 2
  4. Elena Labajo-González 2
  5. Gabriel M Fonseca 1
  1. 1 Universidad de La Frontera Facultad de Odontología Centro Chileno para la Observación y Gestión del Riesgo Sanitario
  2. 2 Universidad Complutense Facultad de Medicina Escuela de Medicina Legal
Zeitschrift:
International Journal of Odontostomatology

ISSN: 0718-381X 0718-3801

Datum der Publikation: 2017

Ausgabe: 11

Nummer: 2

Seiten: 207-216

Art: Artikel

DOI: 10.4067/S0718-381X2017000200014 DIALNET GOOGLE SCHOLAR lock_openOpen Access editor

Andere Publikationen in: International Journal of Odontostomatology

Zusammenfassung

Root cause analysis (RCA) is a retrospective study of adverse events performed to detect the underlying causes of these events to protect patients by modifying the factors within the health system that caused them and preventing their recurrences. Although this paradigm focused on patient safety has seen a significant increase in medical care, dentistry has not been carried out in the same way, probably because of milder injuries, outpatient procedures (with the consequent lack of follow-up of many adverse events) and basically private practices (whose conflicts would potentially affect commercial outcomes). Since there is no precedent in Chile, we present an adverse event produced at the Dental Clinic of the Faculty of Dentistry of the University of La Frontera and its RCA, performed as the first intervention of the Chilean Center for the Observation and Management of Health Risk of that institution. The needs to implement an explicit system of categorization of adverse events in this discipline and to provide support for cultural safety policies for the dental patient are discussed. The role of university institutions in recognizing areas of vulnerability in their clinics and to strengthen and improve the quality of their health practices is also discussed.

Bibliographische Referenzen

  • (2016). ADEA Position Paper: Statement on the Roles and Responsibilities of Academic Dental Institutions in Improving the Oral Health Status of All Americans (As approved by the 2004 ADEA House of Delegates). J. Dent. Educ.. 80. 884
  • Alcota, M.,Ruiz de Gauna, P.,González, F. E.. (2016). Dental programs in the current context of chilean higher education. Int. J. Odontostomat.. 10. 85-91
  • Castillo, H. P. C.. (2016). Seguridad del paciente en los servicios de estomatología. Rev. ADM. 73. 155
  • Charles, R.,Hood, B.,Derosier, J. M.,Gosbee, J. W.,Li, Y.,Caird, M. S.,Biermann, J. S,Hake, M. E.. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient Saf. Surg.. 10. 20
  • Chomali, G. M,Miranda, S. F. (2003). Gestión de riesgos en la atención de salud: Hacia una cultura de la calidad basada en la seguridad. Rev. Clin. Las Condes. 14.
  • Finkler, M.,Caetano, J. C.,Souza Ramos, F. R.. (2015). Formación ética profesional: El paternalismo del vínculo profesor-alumno en la relación clínica. Eidón. 44. 43
  • Fonseca, G. M.,Mira, K.,Beltrán, H.,Peña, K.,Yendreka, V.. (2015). Eventos adversos y demandas por mala praxis en endodoncia. Int. J. Med. Surg. Sci.. 2. 367
  • Kraemer, P.,Vera, L. A.. (2008). Revisión de Estrategias Efectivas para la Seguridad de la Atención del Paciente. Ediciones Ministerio de Salud de Chile. Santiago.
  • Leong, P.,Afrow, J.,Weber, H. P.,Howell, H.. (2008). Attitudes toward patient safety standards in U.S. dental schools: a pilot study. J. Dent. Educ.. 72. 431
  • (2004). Ministerio de Salud Ley 19.937: Modifica el D.L. N 2.763 de 1979, con la Finalidad de Establecer una Nueva Concepción de la Autoridad Sanitaria, Distintas Modalidades de Gestión y Fortalecer la Participación Ciudadana. Gobierno de Chile. Santiago.
  • (2012). Ministerio de Salud Ley 20.584: Regula los Derechos y Deberes que tienen las Personas en Relación con Acciones Vinculadas a su Atención en Salud. Gobierno de Chile. Santiago.
  • Mills, I.,Frost, J.,Moles, D. R.,Kay, E.. (2013). Patient-centred care in general dental practice: sound sense or soundbite?. Br. Dent. J.. 215. 81
  • (2016). National Patient Safety Foundation RCA2 Improving Root Cause Analyses and Actions to Prevent Harm: Second Online Publication, Version 2. The Joint Commission.
  • Pandit, S.,Gong, Y.. (2016). Event reports promoting root cause analysis. Stud. Health Technol. Inform.. 225. 452
  • Peerally, M. F.,Carr, S.,Waring, J.,Dixon-Woods, M.. (2016). The problem with root cause analysis. B. M. J. Qual. Saf.. 26. 417
  • Peleg, O.,Givot, N.,Halamish-Shani, T.,Taicher, S.. (2010). Wrong tooth extraction: root cause analysis. Quintessence Int.. 41. 869
  • Perea-Pérez, B.,Santiago-Sáez, A.,García-Marín, F.,Labajo-González, E.,Villa-Vigil, A.. (2011). Patient safety in dentistry: dental care risk management plan. Med. Oral Patol. Oral Cir. Bucal. 16. 805
  • Perea-Pérez, B.,Santiago-Sáez, A.,Labajo-González, E.. (2011). Análisis causa-raíz (ACR) de un evento adverso en odontología: inyección de una solución de hipoclorito sódico. Cient. Dent.. 8. 27-34
  • Ramoni, R.,Walji, M. F.,Tavares, A.,White, J.,Tokede, O.,Vaderhobli, R.,Kalenderian, E.. (2014). Open wide: looking into the safety culture of dental school clinics. J. Dent. Educ.. 78. 745
  • Ramoni, R. B.,Walji, M. F.,White, J.,Stewart, D.,Vaderhobli, R.,Simmons, D.,Kalenderian, E.. (2012). From good to better: toward a patient safety initiative in dentistry. J. Am. Dent. Assoc.. 143. 956